Gestational trophoblastic disease (GTD) is abnormal growth of placental trophoblasts beyond pregnancy that includes complete and partial hydatidiform moles, invasive moles, choriocarcinoma, and other rare types. GTD is diagnosed based on symptoms like vaginal bleeding, abdominal pain, and constitutional symptoms as well as lab tests and imaging. Treatment involves evacuation of the uterus followed by chemotherapy or other treatments depending on the type and severity of GTD. Close monitoring of hCG levels is also important for detecting and managing persistent or metastatic GTD.
16-Aug-2021-"Gestational trophoblastic disease (GTD) is a spectrum of abnormal growth and proliferation of the trophoblasts of the placenta that continue even beyond the end of pregnancy of the placenta".
16-Aug-2021-"Gestational trophoblastic disease (GTD) is a spectrum of abnormal growth and proliferation of the trophoblasts of the placenta that continue even beyond the end of pregnancy of the placenta".
gestational trophoblastic disease is discussed in its basic knowledge update to enable undergraduate students help understand the disease, diagnose and treat GTD. also enables to follow and detect complications and malignant transformation of molar pregnancy. single drug and multiple dose chemotherapy depending on staging of the disease and related complications & side effects discussed.
gestational trophoblastic disease is discussed in its basic knowledge update to enable undergraduate students help understand the disease, diagnose and treat GTD. also enables to follow and detect complications and malignant transformation of molar pregnancy. single drug and multiple dose chemotherapy depending on staging of the disease and related complications & side effects discussed.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
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June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
2. Gestational Trophoblastic Disease
(GTD) is a spectrum of abnormal
growth and development of the
placental trophoblasts that continue
even beyond the end of pregnancy.
3. GTD includes
- complete & partial H. mole
- invasive mole
- choriocarcinoma
- placental site trophoblastic tumour
- epitheloid trophoblastic tumour
4. Smellie, 1n 1759, defined H. mole as
a conceptus usually devoid of intact
fetus in which all or many of the
chorionic villi show nodular swelling
culminating in cyst formation with
disintegration of blood vessels and
variable proliferation of trophoblasts.
5. Can be complete or partial on the basis
- of gross morphology,
- histopathology
- karyotype.
Incidence-
highest in Philippines 1in 80
Lowest in USA 1 in 2000
In India 1 in 400
6. -maternal age <15 & > 40 years
- prior molar pregnancy(recurrence
1-4%)
-low dietary intake of carotene
-vitamin A deficiency
-ethnic variation( more in Asian)
7. Sporadic
Genetic
Sporadic CHM are usually androgenic
PHM are genetically biparental with
triploid karyotype and arise due to
fertilisation of normal egg by two
sperms.
10. Familial CHM is diagnosed by the
presence of more than 1 woman in a
single family with >2 CHM and is
inherited as autosomal recessive
disorder.
NALP7 is the causative single gene
defect identified in HM.
11. COMPLETE MOLE
1) Fetal or embryonic tissue
absent.
2)Hydatidiform swelling of
chorionic villi diffuse.
3)Trophoblastic hyperplasia is
diffuse.
4) Scalloping of chorionic villi
absent
5)Trophoblastic stromal
inclusions absent.
6)Karyotype 46,XX(90%),
46XY
7)Theca lutein cysts common
8)HCG levels are
high(>50,000)
9)Risk of persistent GTN 20%
PARTIAL MOLE
1)Present
2) Focal
3)Focal
4) Present
5) Present
6) Triploid
7)Uncommon
8)(<50,000)
9)<5%
12.
13.
14. 1) VAGINAL BLEEDING
- Most common symptom
- Occur in 84% of patients
- Apperance of “white currant in red currant
juice”
2) ABDOMINAL PAIN
3)CONSTITUTIONAL SYMPTOMS
-hyperemesis (15%)
-Breathlessness(2%)
-thyrotoxic features of tremors & tachycardia(2%)
4)expulsion of grape like vesicles
5)H/O quickening is absent
15. Features suggestive of early pregnancy
Features of preeclampsia are present in 50%
P/A
size of uterus > POG in 70%
= POG on 20%
< in 10%
feel of uterus is doughy
Fetal parts not felt
Absence of FHS
Vaginal examination-
-internal ballotment absent
-theca lutein cysts palpable
-vesicles in vaginal discharge
-if cervical os is open instead of membranes
blood clots and vesicles may be felt
16. COMPLETE MOLE- After molar
evacuation , local uterine invasion
occurs in 15% of patients and
metastasis in 4% and 80% cases
enter complete remission.
@Partial H. Mole- persistent tumour
usually non metastatic develop in
2-4% of patients.
18. Full blood count, ABORH
Hepatic, renal and TFTs
USG(snow storm appearance)
Quantitative estimation of chorionic
gonadotrophin(urine and serum)
X Ray abdomen & chest
19.
20. Ploidy analysis, flow cytometry or
digital image analysis can
differentiate b/w diploid and triploid
lesions.
Use of p57 immunostaining to make
a definitive diagnosis of androgenic
CHM as apposed to hydropic abortion
or PHM.
24. Principles of management are
1)Supportive therapy to restore blood
loss and to prevent infection
2)To evacuate the uterus as soon as
diagnosis is made
3)Follow up for early detection of
persistent trophoblastic disease.
25. Patients can be grouped as
1)Mole in process of expulsion’
2) Uterus is inert
26. Start I.V infusion and arrange blood.
Suction should be done
A negative pressure of 200-250mm
is applied
Suction cannula of 12mm size is
usually sufficient
Anticipating the risk of haemorrhage
oxytocin infusion may be added.
27. Evacuate the uterus as soon as
diagnosis is made
If the cervix is favourable suction
evacuation is done and oxytocin
started after evacuation is complete.
If the cervix is unfavourable slow
dilatation can be done by introducing
laminaria tent or vaginal PGE1 3 hrs
before the procedure.
28. HYSTERECTOMY-
- in perforating H. mole
- ovaries may be preserved even in
presence of theca lutein cysts.
- patients still require follow up with
HCG levels as the hysterectomy
does not prevent metastasis.
29. PROPHYLACTIC CHEMOTHERAPY-
It not only prevents metastasis but
reduces the incidence and morbidity
of local uterine invasion
Three cycles of MTX and folinic acid
should be given at interval of 14
days.
30. High risk factors are –(for malignant change)
Serum β-HCG levels > 100,000 IU/ml
Bilateral theca lutein cysts > 6 cms
Maternal age > 40 years
Patients having 3 or more births irrespective of age
Uterine size >20 weeks
Previous history of molar pregnancy
associated pre-eclampsia , coagulopathy ,
trophoblastic embolisation and /or hyperthyroidism
h CG levels fail to become normal by 7-9 weeks or
there is re- elevation
Histologically diagnosed as infilterative mole
e/o metastasis irrespective of level of h CG
Women unreliable for follow up.
31. - enquire about irregular vaginal bleeding,cough
breathlessness or haemoptysis.
- abdomino-vagimal examination is done to note
the involution of uterus,ovarian size,malignant
deposit in anterior vaginal wall
- Patients should be monitored weekly with
hCG levels until these levels are normal for 3
consecutive weeks followed by monthly
determination until levels are normal for 6
consecutive months.
- CHEST Xray should be done before treatment ,
4 weeks after evacuation, and then at 3rd
, 6th
and 12th
month
32. Avoid pregnancy during first 6 months
of normalisation of HCG levels
IUCD should not be inserted until
patient achieves a normal h CG level
due to risk of uterine perforation and
irregular bleeding.
Barrier method and surgical
sterilisation are other options
OCP s should not be used until
normalisation of HCG levels
34. Non metastatic ( confined to uterus)
Metastatic
LOW RISK
-< 4 months duration
-initial serum HCG levels < 40,000miu/ml
-metastasis limited to lungs and vagina
-no prior chemotherapy
-no preceding term delivery
HIGH RISK
-duration > 4 months
-serum HCG levels > 40, 000
-brain or liver metastasis
-failure of prior chemotherapy
-Following term pregnancy
-WHO score>7
35. Evidenced by persistence of
trophoblastic activity following
evacuation of molar pregnancy.
Patient presents with
- irregular vaginal bleeding
- subinvolution of the uterus
- persistence of theca lutein cyst
- level of HCG either plateaus or
reelevates after initial fall.
* Postmolar GTN can be invasive mole or
choriocarcinoma but after non molar
pregnancy is always choriocarcinoma.
36. Criteria for diagnosis of GTN or post
molar GTD-
1) plateau of serum HCG level for 4
measurements during a period of 3
weeks or longer
2)rise of serum HCG >10%during
three consecutive measurements or
longer during a period of 2 weeks
3)Serum HCG levels detectable for 6
months or more
4)histological e/o choriocarcinoma
37. It comprises 15% of all GTN.
It is CHM or PHM that invades the
myometrium.
Prominent features are invasive and
destructive.
Shows abnormal penetration through the
muscle layers of the uterus.
Uterine wall may be perforated at multiple
sites showing purple fungating growth.
Neoplasm may invade the pelvic blood
vessels and metastasises to vagina or
distant sites
38. DIAGNOSIS-
-on laparotomy there is perforation of
the uterus through which purple
fungating growth is visible.
- Hemoperitoneum
- On histology there is penetration of the
uterine wall by the hyperplastic
trophoblastic cells which retain villous
structure.There is no evidence of
muscle necrosis.
- Persistent high levels of urinary and
serum HCG .
39. Tumour arises from the trophoblasts of the placental
bed.
Incidence is 1% of all patients with GTN.
15-20 % of these patients develop metastasis.
Most commonly follows a normal pregnancy
Syncytiotrophoblasts are absent and intermediate
trophoblast cells are predominant.
Usual presentation is irregular vaginal bleeding.
Spreads locally through uterine wall and to pelvic
lymph nodes as well as lungs, brain and elsewhere.
HCG levels are low but hPL is secreted.
Not responsive to chemotherapy
Hysterctomy is the preferred treatment.
41. INCIDENCE
- occurs in 4% of patients after
evacuation of complete mole
- Seen more often when GTT develops
after non molar pregnancy. Incidence
following non molar pregnancy is 1 in
50,000.
42. Naked eye appearanc
- leison is usually localised nodular type.
-Red, haemorrhagic and necrotic
Microscopic appearance
- anaplastic sheets of trophoblastic cells
invading the uterine musculature
-e/o necrosis and haemorrhage
-villus pattern is completely absent
Bilateral lutein cysts are present in 30%
cases.
43. There is history of molar pregnancy,
term pregnancy, abortion or ectopic
pregnancy
Patient presents with persistent ill
health, irregular vaginal bleeding,
amenorrhea.
45. Patients present with chest pain, cough,
hemoptysis, dyspnea
On CXR lungs involvement is visible in 80%
of patients.
On CXR
1) snowstorm pattern or cannon ball
appearance.
2) discrete rounded bodies
3) pleural effusion
4) an embolic pattern caused by pulmonary
arterial occlusion
46. These leisons are highly vascular and
bleed vigorously.
Metastasis to vagina can occur in
fornices or suburethral and may
produce irregular bleeding and
purulent discharge.
47. Hepatic metastasis (10%)
- epigastric or right upper quadrant pain.
- can be complicated by hepatic rupture and
intraperitoneal bleeding.
- presents with epigastric pain and jaundice
Central nervous system(10%)
- patient may develop acute focal neurologic
deficits and presents with headache,
convulsion, paralysis and coma.
48. Patient looks ill.
On bimanual examination
- there is subinvolution of uterus
-purplish red nodule in lower third of
vagina
-unilateral or bilateral enlarged
ovaries.
49. All patients should undergo
- complete history & physical examination
- measurements of serum HCG levels.
- hepatic, thyroid and renal function tests.
- baseline peripheral WBC and platelets.
-diagnostic uterine curettage
Metastatic work up should include
-chest radiograph and CT scan.
- USG and CT scan of abdomen & pelvis
- CT and MRI of head.
- pelvic doppler USG
50. On doppler study low PI of uterine
arteries is an adverse prognostic
factor.
All patients with lung metastasis
should have lumber puncture and
measurement of CSF HCG.
A CSF : serum h CG ratio> 1:60 is
highly suggestive of presence of CNS
metastasis.
51. Β-hCG
Produced by
syncytiotrophoblasts
Present through. out
the normal
pregnancy
in all forms of GTD
Method of action is
endocrine
Maintains progesterone
production
hCG-H
Invasive
cytotrophoblasts
Present in implantation
phasesof normal
pregnancy
GTN
Paracrine
Promotes trophoblastic
growth and invasion
52. False negative results can occur if all forms
of β-hCG are not detected.
False positive results can occur due to cross
reactivity with heterophile antibodies
Persistent low level elevation of
β-hCG without clinical or radiological
evidence of active GTD in
-Quiescent GTN
-Pituitary derived hCG
-Non –gestational neoplasia
-physiological elevation
53.
54.
55. It predicts the potential for resistance to
chemotherapy.
Score 0-6 is low risk
>7 is high risk
With in high risk group adverse prognostic
factors
1)Longer duration from antecedant pregnancy
2)Liver metastasis
3)Combined liver & brain metastasis
58. Blood counts, liver fn tests, kidney fn tests daily
X- ray chest repeat only if hCG titres plateaus
or rises.
Serum hCG weekly
Treatment should not be repeated if
- WBC < 3000 cu mm
- polymorphonuclear leucocytes <1500 cu mm
- platelet count < 1 lakh /cu mm
- Significant elevation of BUN , SGPT
Continue treatment at 1-3 weekly interval until
3 consecutive negative weekly hCG titres.
Continued for consolidation phase of 6-8 weeks
after normalisation of h CG levels.
59. 1) histological e/o of choriocarcinoma
2) E/O metastasis in brain, liver,git or radiological
opacity > 2cm on CXR.
3) Pulmonary, vaginal or vulval metastasis unless
h CG levels are falling
4) Heavy vaginal bleeding with E/O git or
intraperitoneal perforation.
5) Rising hCG after evacuation.
6) Serum hCG >20,000 more than 4 weeks after
evacuation.
7) Elevated hCG 6 months after evacuation even
if falling..
60. Single agent chemotherapy with
either Actinomycin D or MTX has
achieved excellent remission in non
metastatic and low risk metastatic
GTN.
MTX can be given along with folinic
acid to reduce the toxicity.
61. Methotrexate ,which is chemically 4-amino-n10
-methyl-
pteroylglutamic acid ,is a folate antagonist .
It causes irreversible inhibition of enzyme DHF reductase and
blocks the conversion of DHF to THF ,required for denovo
purine synthesis(hence DNA synthesis).
It kills the neoplastic cells during S-phase of cell cycle.
62. If the response to first treatment is
adequate dose is unaltered.
If the respone is inadequate dose is
increased from 1.0mg/kg per day to
1.5mg/kg per day for each of the 4
treatment days.
If the response to 3 consecutive
courses of MTX-FA is inadequate
patient is resistant to MTX and
Actinomycin is substituted.
63. If the hCG levels do not decline by 1
log after treatment with Actinomycin,
must be treated with combination
chemotherapy.
65. methotrexate 1-1-5mg/kg IM/IV 1,3,5,7
Folinic acid 0.1-O.15mg/kg I/M 2,4,6,8
Actinomycin D 12ug/kg IV Days 1-5
Cyclophosphami
de
3 mg/kg IV Day 1-5
66. 1) Triple therapy
2) EMA-CO
3) EMA EP
4) paclitaxel+cisplatin alternating
with paclitaxel+etoposide
67. DRUG DOSE
DAY 1 ETOPOSIDE 100mg/m2 in 200 ml
saline infused over 30
min
ACTINOMYCIN D 0.5 mg IV bolus
METHOTREXATE+FOL
INIC ACID
100mg/m2 bolus
followed by
200mg/m2 IV
infusion over 12 hrs.
DAY 2 ETOPOSIDE 100mg/m2 in 200 ml
saline infused over 30
min
Actinomycin D 0.5 mg IV bolus
FOLINIC ACID 15 mg IM every 12
hrs for 4 doses
starting 24 hrs after
methotrexate
DAY 8 CYCLOPHOSPHAMIDE 600 mg /m2 IV
69. Triple therapy with MTX ,Act-D, and
cyclophosphamide is inadequate as an
initial treatment in patients with
metastatic and high risk prognostic
score.
EMA-CO includes etoposide, MTX, Act-
D, cyclophosphamide and vincristine.
It is the preferred primary treatment in
patients with metastasis and high risk
prognostic score.
70. If the patient is resistant to EMA-CO
then they should be treated by
substituting etoposide and cisplatin
on day 8(EMA-EP)
Combination therapy should be given
as often as toxicity permits until the
patient achieves 3 consecutive
normal hCG levels.
After normal hCG levels, at least 2
additional courses of chemotherapy
are given to reduce the risk of
relapse.
71. After completing chemotherapy pelvic
USG done and any investigation that
was abnormal at diagnosis.
Residual brain leisons are excised with
stereotactic radiotherapy.
Residual leisons at othervsites are not
resected and follow up done by
h CG levels.
Complete serological response is
necessary not the radiological response
72. Relapsed high risk disease is defined by a rising hCG
after complete serological response to EMA-CO
therapy(having atleast 6 weeks of normal hCG values
post chemotherapy.
Resistant cases are those that have a rising or
plateaued hCG levels while on EMA-CO.
FDG-PET may be used to locate the site of disease.
Treatment is surgical resection+postoperative
chemotherapy
Second line of chemotherapy is EMA/EP :weekly
alternating regimen of EMA and etoposide+cisplatin
Another alternate is Paclitaxel+Cisplatin alternating
with Paclitaxel+ Etoposide
73. HCG conc
YEAR 1 -WEEKS 1-6 AFTER
CHEMOTHERAPY
-2-6 MONTHS
-7-12 MONTHS
-WEEKLY
-2WEEKLY
-2 WEEKLY
YEAR 2 4 WEEKLY
YEAR 3 8 WEEKLY
YEAR 4 3 MONTHLY
YEAR 5 4 MONTHLY
YEAR 6 OR ABOVE 6 MONTHLY
74. Indications of surgery-------
Leisons confined to uterus in women > 35 years
Localised uterine leison resistant to
chemotherapy.
Intractable bleeding or accidental uterine
perforation.
Persistent viable pulmonary metastasis after
intensive chemotherapy
Cerebral metastases resistant to chemotherapy
Surgery- total hysterectomy, lung resection ,
craniotomy.
75. Patients with brain metastasis
require whole brain radiation
therapy(3000cGY ocer 10 days)
In liver metastasis hepatic artey
ligation or embolisation or whole liver
radiation (2000 c GY over 10
days)along with chemotherapy may
be effective.
76. Non metastatic GTN 2-3%
Good prognosis metastatic GTN 3-5%
Poor prognosis disease 21%
Recurrence after 12 months of normal
hCG level <1%
Additional cycles of chemotherapy after
normalisation of hCG levels are 1 in
non metastatic , 2 in good prognosis
metastatic and 3 in poor prognosis
metastatic disease to prevent
recurrence.
77. H. MOLE
Evacuation
Serial HCG levels Resolution(FU)
GTN
Low risk High risk
Single agent combination
serial HCG levels
relapse Resolution, life long FU